Reviewers' responses to medical research articles

Objective: To document the reviewers' responses in terms of reviewers' demographic and professional characteristics, promptness of reply, and duration of reply to the request to review medical research articles for a general biomedical research journal

Study Design: Cross-sectional, observational study

Place and Duration Of Study: Department of Publications, College of Physicians and Surgeons Pakistan [CPSP], from October to December 2015

Methodology: Peer reviewed articles edited by a single staff editor were included. Editorials and correspondence were excluded. Manuscript category, discipline, and the total number of reviewers per manuscript were noted. Responses were divided into no response, regrets, and responded, i.e. provided with the review comments; and further sub-divided into timely response, i.e. within 21 days, or later. Total duration of response was counted in days from the date of dispatch to the date of receiving. Among those who provided a review, reviewers' characteristics were noted as designation, institute affiliation, qualification, and gender. Number and percentages of the studied variables were determined. Chi-square test of proportions was used for comparing the proportions with significance at p<0.05

Results: Reviewers for 50 articles including 28 original articles, 15 case reports, three letters to the editor, two short communications, and two new techniques, were evaluated. A total of 598 reviewers were contacted for those 50 articles; forming an average of 11.96 reviewers contacted and 2.2 responded per manuscript. Four hundred and seventy [78.59%] did not reply at all, 18 [3.01%] regretted, and 110 [18.39%] responded [79/110=71.81% timely, and 31/110=28.18% late]. Earliest reply was received in one day and the delayed reply in 87 days. Maximum number of reviewers was 24 for a single original article [internal medicine] and 22 for a case report [cardiology]. Significantly, more fellows, professors and females [p=0.004, p=0.002, and p=0.017, respectively] provided timely response

Conclusion: An overwhelming majority of the reviewers did not reply at all despite the incentives of CME credits and honorarium, adversely affecting the processing time. Majority of those who replied, were on time. Reasons for those who did not reply need to be explored

Cervical teratoma: a management challenge

Congenital cervical teratomas are rare germ cell tumors. Most of these are benign in nature but their management remains challenging due to grotesque size, posing life threatening airway compromise. When decision of surgical removal is made then anesthesia related issues need proper planning so as to ensure control of airway both during induction and surgery. We report two cases of cervical teratomas in whom total excision was performed

Low lying umbilicus in a neonate with anomalous position of penis and anus

A healthy thriving neonate was brought with the complaint of passage of stool like material from glans penis. In this healthy baby umbilicus was found to be placed caudally 4cm above symphysis pubis. The penis was located away from scrotum and anus was anteriorly placed with mucosal protrusion. There were no complaints related to passage of urine and stool. Extensive investigations revealed no associated anomaly and any communication between urinary tract and anorectal canal. Reassurance was given to the family and advise for regular follow up given

Blast Injuries in Children and Adolescents

Objective: To find out pattern of injuries, treatment provided and outcome of blast injuries in children including adolescents

Study design: Case series

Place and duration of study: Department of Paediatric Surgery National Institute of Child Health [NICH] Karachi, August and October 2013

Methodology: Demographic data of the blast victims, nature of the blast, treatment received before arrival to NICH, injuries found and treated, complications and outcome in terms of discharge, referred or death was entered into a performa. Descriptive statistics were used to present data

Results: Two incidents occurred during the study period. A total of ten children and adolescents were injured. In incident 1, bomb blast occurred after a football match. The bomb was planted in motorbike and was detonated with remote control. In incident 2 blast occurred when extortionist hurled hand grenade into a clinic of a doctor. Victims received multiple injuries. Of the total three children needed chest intubation in ER after needle thoracentesis for life threatening tension pneumothorx. A total of five laparotomies and one laparoscopy were performed. Hollow viscera were involved both due to blast wave and penetrating missile. Small bowel was involved in most [n=4] and colon in two patients. No intraperitoneal breach was found in patient who underwent laparoscopy. One patient lost his eye sight while in one patient was found paraplegic at tertiary survey. No mortality occurred in this series

Conclusion: The pattern of blast injuries were not different from what is reported from other centers. An organized approach using ATLS protocol was found useful in managing victims. Hollow visceral injuries were found in most of the cases

Cystic lesions of lung in infancy

Objective: to describe clinical presentations, investigations performed for diagnosis, treatment provided and outcome of cystic lesions of the lung in infancy

Study design: descriptive case series

Place and Duration of Study: department of Paediatric Surgery, National Institute of Child Health Karachi, from January 2010 to February 2012

Methodology: infants admitted with respiratory distress and later suspected of having structural / anatomical cause for the dyspnea were included. X-ray chest was performed in all the cases. CT scan was advised for detail assessment

Results: a total of twelve patients were managed during the study period. There were seven male and five female patients. Seven lesions were in left lung and five in right lung. This included seven cases of congenital lobar emphysema [CLE], two of pneumatocele, one each of bronchogenic cyst, isolated lung cyst and necrotizing pneumonia. All patients underwent thoracotomy and procedure was tailored according to the pathological lesion. Excision of involved segment of lung was performed in cases of CLE [five left upper lobes and two right middle lobes] and necrotizing pneumonia [right upper lobe]. Lung cyst was found in the fissure between right upper and middle lobes. In two cases of pneumatocele cyts were opened and after partial excision of the wall. Margins of cysts were over sewed. In a single case of bronchogenic cyst which was adherent to left bronchus excision of cyst and repair of bronchus was done. One patient died in this series

Conclusion: cystic lesions presents in a spectrum; most common being acute respiratory distress. An early diagnosis and prompt surgical intervention is required to prevent morbidity and mortality

Laparoscopy in children

Objective: To analyze data related to different laparoscopic procedures performed on children so as to document pattern over the years at a public sector hospital

Study design: Retrospective chart review

Place and Duration of study: Department of Paediatric Surgery National Institute of Child Health Karachi, from January 2011 to December 2013

Methodology: The data of all the laparoscopic procedures was reviewed for the indications, type of surgical procedure performed, operative details including time taken for completion of the procedure, difficulties / conversion rate and complications. Data was entered into SPSS version 16 and descriptive statistics were used for analysis

Results: Total number of patients who underwent laparoscopic procedure was 201. There were 164 [81.6%] males and 37 [18.4%] females. Most of the patients [n=122 - 60.7%] were above five year of age. Clinically impalpable testis [n=124 - 61.7%]] was the most common surgical condition for which laparoscopy was performed. This included first, second stage Stephen Fowler procedure, single stage orchiopexy and orchiectomy. Other procedures included appendectomy [n=27-13.4%] and cholecystectomy [n=12 - 6%]. Diagnostic laparoscopy was performed in 11 [5.5%] babies with persistent jaundice to find out surgical cause of hyperbilirubinemia. There were 7 [3.4%] cases with disorders of sex development [DSD]. Complications occurred in 19 patients which included port site infection [n=8], port site bleeding [n=5], bowel injury [n=2] and others. In only seven [3.5%] cases procedure was converted to open surgery

Conclusions: Laparoscopy was a safe surgical procedure in children performed for different indications. Learning curve over period improved procedure related outcome

Hirschsprung's disease: pattern of clinical presentation

To report clinical symptoms and signs and age at initial presentation of patients with Hirschsprung's disease. Descriptive case series. Department of Paediatric Surgery, National Institute of Child Health Karachi, From September 2008 to December 2013. Patients who were proven cases of Hirschsprung's disease on rectal biopsy report were included. The data was collected prospectively. Variables recorded included clinical presentation including symptoms, signs, age, gender, mode of presentation either elective or acute etc. The data was analyzed using descriptive statistics like frequency, percentage and proportions in relation to quantitative and qualitative variables. A total of 84 patients with Hirschsprung's disease were managed during the study period. There were 63 male and 21 female patients with male to female ratio of 3:1. Fifty-five [65.5%] patients belonged to Karachi. Fifty percent [n=42] patients presented by day 6 of life. The commonest presentation was delayed passage of menonium but it was reported in 39 [46.4%] patients only. All these patients were operated and extent of the disease was up to rectosigmoid level in 78 [93%] patients. Clinical presentation in present study had similarities to reported literature but important differences were noted with regards to passage of meconium and extent of aganglionosis

Neonatal duodenal obstruction: clinical presentation and outcome

To find out causes, modes of presentations and surgical outcome in neonates with duodenal obstruction. Descriptive case series. Department of Paediatric Surgery National Institute of Child Health [NICH] Karachi, from September 2011 to August 2013. All neonates presenting with duodenal obstruction were included. Age at presentation, symptoms and signs, associated anomalies, treatment provided and outcome were recorded. Investigations done included CBC, serum electrolytes, urea / creatinine, x-ray abdomen and echocardiography. Surgical procedures were tailored according to the cause of obstruction. Data was recorded on a performa. Analysis was done using SPSS version 17. A total of 17 patients [males 13, females 4] were managed. Age ranged from 1 day to 20 day [mean=4 day]. Weight of the babies ranged from 1.5 kg to 3.0 kg [mean=2.24 kg]. One patient was delivered via cesarean section. The causes of obstruction were duodenal atresia [n=8], annular pancreas with duodenal atresia [n=4], annular pancreas with duodenal atresia and malrotation [n=3] and only malrotation [n=2]. Double duodenal atresia was present in one patient. Associated imperforate anus was found in five cases, multiple atresias of gut and jejunal atresia in one case each. Three patients had Down syndrome. All patients were operated. Two patients had anastomotic leak. A total of seven patients survived. Those who expired had duodenal atresia [n=5], annular pancreas group [n=4] and malrotation [n=1]. Sepsis was the major contributor to the mortality. Late presentation with low birth weight were the salient observations. Multiple associated gut related surgical anomalies added to operative stress. High mortality [59%] was of concern and sepsis remained the major contributor

Comparison of eutectic mixture of local anesthetics cream with dorsal penile nerve block using lignocaine for circumcision in infants

Circumcision is a commonly performed surgical procedure but choice of anesthesia remained an issue of research and debate. This study was conducted to find out the effectiveness of the eutectic mixture of local anesthetic [EMLA] cream with dorsal penile nerve block [DPNB] using lignocaine, for reduction of pain during circumcision. This was comparative study carried out in Surgical Unit B of National Institute of Child Health Karachi, from May 2008 to October 2008. Patients under six month of age were randomized in to two groups [EMLA and DPNB] of fifty patients each. The effectiveness of pain control was assessed by measuring the baseline heart rate [HR], respiratory rate [RR] and Neonatal infant Pain Scale [NIPS scale] before the start of procedure and measuring of these parameters for each step of circumcision. Independent sample t -test was used to compare means and repeated ANOVA was used to compare means of HR, RR, oxygen [O2] saturations and NIPS. The mean age in both the groups was 2.3 months. There was no statistically significant difference in baseline parameters in both the groups except the respiratory rate, which was significantly raised in DPNB group [33 breaths/min in EMLA and 38 in DPNB P < 0.04]. During circumcision there was significant increase in heart rate in DPNB group, especially in step three and step four [p < 0.04]. Oxygen saturation dropped in both the groups [baseline saturation 98% up to 91% in step 4]. While assessing NIPS scores in both the groups, statistically significant difference was found between NIPS at step two and step four in two groups [p < 0.04]. The overall pain control was equal in both the groups, although NIPS score was higherin DPNB in step two and four of circumcision. There was difference in application and cost. EMLA was easy to apply but has increased cost; while DPNB required expertise

Omphalomesenteric duct cyst in an omphalocele: a rare association

Omphalomesenteric duct [OMD] remnants and omphalocele are not infrequently seen in paediatric patients. In most of the cases, OMD remnant in an omphalocele is a Meckel's diverticulum; however rarely there may be other lesions. A one-day old male baby underwent surgery for omphalocele. At exploration a 10 x 12 cm cyst containing gut contents was found as the content of the omphalocele, with proximal and distal ileal loops running in continuity with it. Resection of the cyst with end to end primary gut anastomosis was done. Baby also had complex associated cardiac anomalies and died few days after surgery due to sepsis